Sports medicine

Justin A Paoloni,* John W Orchard† * Conjoint Senior Lecturer, Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, Sydney, NSW. † Sports Physician, Sports Medicine at Sydney University, Sydney, NSW. pao_26AThotmail.com In reply: We thank Masters and Yelland for their interest in this topic and their notification of additional references, some of which were published after our article was written. We stated in our article that “the mechanism of any effect of corticosteroid injections in reducing symptoms in purely degenerative tendinopathies is unknown”, and that only where bursitis or tenosynovitis is present would the implication of an anti-inflammatory effect be appropriate.1 While blocking nociceptive C-fibres in normal tendon is demonstrated in the study quoted by Masters and Yelland,2 we still believe that corticosteroids should be used with caution for any tendinopathy where tendon weakening would be potentially harmful. We agree that corticosteroids have a much greater potential role in low back pain, which is a broad entity involving both soft-tissue and joint disorder. At the time of writing our article there was a pilot study on polidocanol in painful tendons displaying neovascularisation;3 we thank the authors for advising that a randomised controlled trial has since been published.4 While undoubtedly an exciting new therapy, proponents of polidocanol do not consider its mechanism to be simply a “prolotherapy” effect; they also consider sclerosing the neovessels to be critical, and therefore, that hypertonic glucose (the most commonly recommended prolotherapy agent) may not work as well. We still maintain that prolotherapy currently lacks evidence of efficacy for the treatment of soft-tissue injury in general, although it is relatively cheap and generally free of side effects. Both chronic low back pain, and chronic groin pain, are multifactorial conditions involving joint/bone abnormality which we considered slightly beyond the scope of an article on soft-tissue injuries. We await further publications on the efficacy of prolotherapy with interest.

Justin A Paoloni · John W Orchard

Antidoping laws generally exist in order to provide a safe and fair environment for participation in sport. These laws should prevent and protect athletes from subjecting themselves to health risks through the use of unsafe, but performance-enhancing drugs. Because of difficulties in proving intent to cheat, the World Anti-Doping Agency enforces a principle of strict liability for positive test results for banned substances. An area of major controversy with respect to liability is the “sports supplement” industry, which is poorly regulated when compared with prescription drugs yet is a potential source of doping violations. Medical practitioners can be found guilty of anti-doping violations if they traffic banned drugs, prescribe these to athletes or otherwise assist athletes in taking banned substances. Medical practitioners are also now required to complete paperwork (therapeutic use exemption forms) to enable athletes to take banned substances which are required on medical grounds for specific illnesses.

John W Orchard PhD, FACSP, FACSM · Deborah J Healey LLM · Peter A Fricker OAM, MB BS, FACSP · Louise M Burke PhD, APD, FACSM · Susan L White MB BS. FACSP

John W Orchard Visiting Fellow, South Sydney Sports Medicine, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: I congratulate Harris et al1 on conducting a survey that identified aspects of specialty training that are difficult for female doctors and doctors with partners and/or children. However, there are some omissions in their article, which, although small, illustrate further ways in which “specialty” training is unfriendly to the aforementioned groups. The authors purported to survey all medical graduates registered in 2002 “with a clinical college training program”. It appears that registrars on the Australasian College of Sports Physicians (ACSP) training program were not included. This training program has been in place since 1992, has been recognised by the Health Insurance Commission since 1999, and is most definitely a “clinical college training program”. Although similar in structure, there are two major differences between the sports physician training program and most other “specialty” training programs; namely, that the training is almost entirely non-hospital based and that the resulting qualification (the FACSP) is not recognised as a “specialty” in Australia. In 2002, I believe that the Australasian College of Sexual Health Physicians was in a similar position to the ACSP, administering a “non-specialty” clinical college training program (which is now under the auspices of the Royal Australasian College of Physicians). The recognised specialties in Australia, with the major exception of general practice, almost all conduct most of their training in hospitals. Not only are these hospital-based positions relatively “female-unfriendly” and “parent-unfriendly”, they don’t adequately train specialists for the majority of doctor–patient interactions, which do not actually take place in hospitals. They also contribute to the reality that our “health” system is focused on treatment of disease rather than prevention.2 Areas such as women’s and men’s health, travel medicine and dietary medicine also exist within our health system.3 Ideally, if we want a health system that is better at actually promoting health, these areas should also have formally recognised training programs. The conservatism of both the Australian Government and the medical profession is reflected in the process for recognising new specialties, which has severely discouraged community-based specialties from being developed. The “choice” of specialty training that Harris et al examined in their study was limited by what was officially sanctioned in 2002. If it were accepted that there should be more recognised specialty postgraduate training positions in community-based fields of medicine, then not only would our medical system start to address its deficiencies in health promotion, but there would be far more attractive training opportunities for doctors who don’t wish to pursue full-time hospital-based positions.

John W Orchard

Physical activity can significantly reduce the risk of cardiovascular disease, diabetes, some forms of cancer, osteoporosis, obesity, falls and fractures, and some mental health problems. While the benefits of physical activity are clear, there is a slightly increased risk of sudden death while exercising (compared with while sedentary), especially in untrained people undertaking unaccustomed vigorous activity. Routine exercise testing yields a significant number of false-positive results, and has not been shown to prevent exercise-related acute cardiac events. There is no convincing evidence that exercise is itself associated with osteoarthritis, but significant joint injury which occurs during sport is associated with an increased risk of subsequent development of osteoarthritis.

Peter D Brukner MB BS, FACSP · Wendy J Brown BSc(Hons), MSc, PhD

Imaging should only be undertaken if it is likely to influence patient management. The dose of ionising radiation to the patient should be considered. Requesting the appropriate imaging method requires an understanding of the pathological process. Plain x-ray should still generally be the first imaging technique; exceptions include some forms of superficial tendinopathy, in which ultrasound may be more appropriate, and situations where radiation exposure is contraindicated, such as in a pregnant patient. The cost of the examination to the patient and the community should also be considered (eg, ultrasound v magnetic resonance imaging).

John W Orchard PhD, FACSP, FACSM · John W Read MB BS, FRANZCR, DDU · Ian (Jock) F Anderson MB BS, FRANZCR, FRACSP(Hon)

The recent epidemic of sleep deprivation during the dramatic Ashes cricket series has once again highlighted the Australian passion for sport. A drive around city suburbs or country towns on a weekend may reassure one that thousands of Australians are still playing sport. However, such reassurance should be tempered by data which suggest that we are increasingly doing the driving rather than the playing.1-3 For example, the proportion of children and their parents who were physically active in Australia dropped between 5% and 11% from 1985 to the late 1990s.4 The importance of physical activity in the fight against obesity and its associated negative effects on health is becoming more evident. The role of exercise in preventing diseases such as coronary heart disease, diabetes, various forms of cancer, osteo-porosis and mental health problems is well documented, and rivals smoking cessation as a preventive measure.3 Although experts agree that many people should exercise more, injury and disability are consistent barriers to achieving this aim.5,6 The medical discipline of sports medicine has emerged over the past two decades and evolved from being a service to elite sportspeople into “the medicine of exercise”. While many of the advances in treating sporting injuries have come from the world of professional sport (where it is most costly to rest), these benefits, and the mentality of “keeping the player on the field”, are now available to the broader community. As a relatively young area of medicine, sports medicine lags somewhat behind some of the more traditional specialties in the amount of evidence-based medicine it can offer, but it is making rapid progress. In one article in this series, the overall evidence in favour of participation in sports and exercise is weighed up against the costs of long-term health problems that vigorous exercise can bring. Other articles look at some of the recent advances in sports medicine and practicalities such as the role of the “doctor on the sidelines”. In selecting the topics for this series, we have tried to balance the areas where sports medicine has made most progress in recent years (eg, use of therapeutic drugs in sport, and radiological imaging) with those where it must make most progress in the next few (eg, sports medicine in special groups such as older athletes and children). The increasing demand from the community for sports medicine expertise has led to the development of medical specialisation in this area. The Australasian (formerly, Australian) College of Sports Physicians (ACSP) was formed in 1985 with the aim of developing the specialty in this country. Over the past 20 years, this has been achieved with the development of a curriculum, entrance and exit examinations, and the creation in 1992 of a 4-year full-time training program in sports medicine, which is regarded as a world leader in the field.7,8 There are now about 110 Fellows of the College practising in Australasia and overseas. Fellows may be in private practice (either solo or in a multidisciplinary environment), may service professional and national sporting teams or may work for Institutes of Sport, the Australian Defence Force or for private bodies such as workers compensation insurers. It must be said that other professional bodies such as medical schools, the Royal Australian College of General Practitioners, the Australian Medical Council and the Health Insurance Commission have been slow to acknowledge the existence of the specialty and its accompanying high-quality training program.7,8 The resultant “out of pocket” expenses for consulting sports physicians (resulting from lower-tier Medicare recognition) mean that the benefits of this specialty have not been realistically available to those in the community who rely on the public system. If the specialty of sports medicine in Australia is finally recognised by the appropriate authorities, the next major challenge in Australia is the establishment of a national sports injury surveillance system.9 Managing sports injuries as they occur is important, but preventing them (which starts with surveillance10) is perhaps more important, and other countries like New Zealand and Norway are much further advanced in this regard.9,11 We trust that readers will read and enjoy these summaries of recent research in sports medicine, a new and exciting field of medicine which is attracting graduates with an interest not only in sport, but in the benefits of exercise to the community.

John W Orchard MB BS, BA, FACSP · Peter D Brukner MB BS, DRCOG, LACSP

Soft-tissue injuries are injuries to skin, fascia, ligament, muscle, and tendon. Currently, many therapeutic medications are commonly used in the management of soft-tissue injuries, including: analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, prolotherapy sclerosant agents, aprotinin, glyceryl trinitrate, botulinum toxin, and glucosamine. Despite their regular use for soft-tissue injury, few medications have strong evidence of a consistent therapeutic effect. In this article, we review the proposed mechanisms of action, side effects, and the evidence base (based on National Health and Medical Research Council levels of evidence1) for common soft-tissue injury treatments. We also suggest appropriate circumstances for using therapeutic medications, with emphasis on the Hippocratic principle of primum non nocere (first do no harm). Non-steroidal anti-inflammatory drugs for ligament and muscle injuryNSAIDs are among the most widely used medications for common soft-tissue injuries such as muscle contusions, muscle tears, and ligament tears. The mechanism of action of NSAIDs is through non-specific cyclo-oxygenase inhibition, thereby blocking the production of prostaglandins from arachidonic acid. Prostaglandin inhibition by NSAIDs decreases the inflammatory response, which can have both positive and negative effects. For example, the arachidonic acid “overflow” pathway may lead to increased leukotriene production and potential tissue damage. Other known negative NSAID class side effects include hypertension, altered renal function, gastrointestinal disturbance (including peptic ulceration), and the recently discovered increased rates of myocardial infarction with non-selective NSAIDs, such as diclofenac and ibuprofen (evidence level III-2 [E32]).2 Potentially desirable class effects of NSAIDs include reduced risk of bowel cancer and increased blood clotting times. Side effects, whether positive or negative, are generally far more relevant for long-term use (such as in patients with rheumatoid arthritis) than with short-term use for sports injury. Many NSAIDs are available as topical preparations. Although the results of tissue penetration studies are variable, for injured body structures which are close to the surface (eg, limbs), topical NSAIDs may offer the advantages of higher local tissue concentrations with reduced risk of systemic side effects. The balance of evidence suggests that NSAID use is associated with a short-term mild to moderate decrease in pain in “minor sports injury” (E2),3 ankle sprains and knee pain (E2),4 and shoulder pain (E1).5 The number needed to treat (NNT) for a positive effect greater than placebo for most conditions is 3–4 patients. There is no evidence that NSAIDs improve muscle function after injury. NSAIDs (and corticosteroids) are catabolic in nature, particularly having their effect on tissues such as the soft-tissue structures of muscles, ligaments, tendon, and fascia, with very little effect on neural tissue. Therefore, in conditions where the pathological disorder is entrapment or impingement of nerves because of soft-tissue proliferation, such as carpal tunnel syndrome, Morton’s neuroma, thoracic outlet syndrome, and intervertebral disc prolapse, there is a strong theoretical basis to support the use of anti-inflammatory medications like NSAIDs (and corticosteroids). There is level II evidence of efficacy of NSAIDs on the inflammatory components of disorders such as bursitis in rotator cuff disease or iliotibial band friction syndrome,6 and synovitis in Morton’s neuroma7 or carpal tunnel syndrome.8 Case study — a torn tendon and bursitis in the shoulder A 46-year-old left-handed woman with a 6-month history of left shoulder pain initially injured the shoulder while playing tennis. She felt a dull ache in the lateral arm immediately after the game, and now has night pain, and pain with activities of daily living. Examination showed restricted range of shoulder motion, muscle weakness, and positive impingement signs. Her x-rays were unremarkable. Ultrasound showed a supraspinatus tendon tear with bursal thickening, and supraspinatus tendon tear with supraspinatus bursitis was diagnosed. Therapy is dictated by the patient’s activity level. If she requires strong overhead function then the goal of treatment should be healing of the tendon tear. However, if she generally only requires use of the arm for activities below shoulder height, then relief of impingement is the primary goal of treatment. Anti-inflammatory treatment for 6 weeks and/or subacromial corticosteroid and local anaesthetic injections (Figure A) are among the best therapeutic options for giving pain relief. These will generally provide analgesia, but may have potentially deleterious effects on tendon healing. Regular use of ice and paracetamol may be used for analgesia as alternatives if healing is considered important. Topical glyceryl trinitrate patches (1.25 mg/24 h) are an appropriate option to help relieve symptoms and increase function with chronic injury (Figure B). Exercise rehabilitation is the cornerstone of managing tendinopathies to regain function — in this situation, concentrating on scapula stabilisation and rotator cuff strengthening. This may be managed by the general practitioner confident in exercise prescription for this shoulder injury, or with the assistance of a sports physician or physiotherapist with experience in rehabilitating such injuries. Surgery may have a role if other treatments are not successful. If the patient requires high levels of shoulder function, direct repair of a tendon tear has a good rate of success, but requires prolonged rehabilitation. Arthroscopic acromioplasty is a procedure with quicker recovery which, like anti-inflammatory agents, is directed at providing pain relief rather than maximising shoulder function. A: Corticosteroid injections for tendon injuries, such as this subacromial injection, provide a short term reduction in pain of 6–8 weeks duration in most soft-tissue conditions. B: Quartered 5 mg/24 h glyceryl trinitrate patch, used for treatment of shoulder tendinopathy. Thus, current evidence does not support NSAID use as solo therapy or long-term therapy for soft-tissue injury, except when the primary disorder is soft-tissue impingement, or predominantly inflammatory (such as bursitis or synovitis). NSAIDs should not be used routinely in soft-tissue injury, as they are, at best, an adjunct to treatment through symptom relief, most notably analgesia (see Case study), and these benefits must be weighed against the risks of gastrointestinal side effects, especially with prolonged use. Non-steroidal anti-inflammatory drugs for tendinopathyThe abnormality in chronic tendinopathy in most cases is degeneration, with no evidence of inflammation (Box 1). Despite this, there is level II evidence that NSAIDs provide short-term mild to moderate decreases in pain in lateral epicondylosis,9 increased abduction in rotator cuff disease,10 but have no efficacy in treating Achilles tendinopathy.11 The mechanism of action of NSAIDs in tendinopathy is unclear. NSAID use decreases fibroblast proliferation and increases “overflow” leukotriene production in tendon both at rest and during exercise, which is additive to the normal effect of increased leukotriene production with cyclic tendon loading. So, there is potential for NSAIDs to cause tendon damage through increased leukotriene formation. Further, as tendinopathies have a tendency to chronicity, the side effects of NSAIDs with prolonged use are an even greater limitation than with other soft-tissue injuries. Thus, the evidence does not support the use of NSAIDs in pure tendinopathy, given their small effect on relieving symptoms and potential adverse effects. Short-term use of ice and paracetamol should provide an equivalent analgesic effect without serious side effects. Non-steroidal anti-inflammatory drugs compared with paracetamol for soft-tissue injuryParacetamol is an analgesic with a centrally mediated mechanism of action. With comparable efficacy to NSAIDs for pain in soft-tissue injury (E2),12 and being both opioid-sparing and NSAID-sparing, it can be used in combination analgesia. It also has a low cost, low side-effect profile, and no risk of local soft-tissue injury. It is often the analgesic of choice for soft-tissue injury. Cyclo-oxygenase-2 (COX-2) inhibitors for soft-tissue injuryCOX-2 inhibitors were developed to selectively block the COX-2 enzyme and the inflammatory process without inhibiting the effects of prostaglandins on gastroprotection or the effects of thromboxane on bleeding time and platelet aggregation. The use of these agents is currently under review because of increased rates of myocardial infarction, with rofecoxib withdrawn from the market and celecoxib only recommended for use in rheumatoid arthritis and osteoarthritis at low dosages. Given the lack of evidence of efficacy for these agents in soft-tissue injury, and significant cardiovascular safety concerns that are yet to be adequately researched, COX-2 inhibitors should generally not be used for treating soft-tissue injuries. They would only be recommended for patients in whom nerve or mechanical impingement is predominant, and non-specific NSAIDs are contraindicated because of a coexisting gastric disorder. They should not be used in patients at high risk of cardiovascular disease. Corticosteroid injections for tendinopathyCorticosteroids are injectable anti-inflammatory medications that inhibit the accumulation of neutrophils and the synthesis of inflammatory mediators, and prevent phagocytosis and lysosomal enzyme release. They have short-term efficacy in symptom relief for degenerative tendinopathies, bringing decreased pain in lateral epicondylosis (E1),13 decreased pain and increased abduction in rotator cuff tendinopathy (E1),14 and decreased pain and increased function in trigger finger (E2).15 However, there does not appear to be a positive effect of peritendinous injections in Achilles tendinopathy (E2).16 Positive results noted in studies occur in, at most, 80% of patients, and are generally limited to 6–8 weeks after injection (Box 1). Longer-term studies (12 months’ follow-up) of the effects of corticosteroid injections in lateral epicondylitis show inferior results to physiotherapy (E2).17 Studies have not shown clinically significant improvements in function with corticosteroid injections (E1) or greater efficacy than NSAIDs for shoulder pain. The demonstrated effect of corticosteroids in decreasing pain of tendinopathies may be the result of improvements in the inflammatory components of tendon injuries such as bursitis in shoulder tendinopathy, and tenosynovitis in trigger finger. The mechanism of any effect of corticosteroid injections in reducing symptoms in purely degenerative tendinopathies is unknown. There is Level IV evidence of tendon rupture with both local corticosteroid injection and oral corticosteroid treatment. This risk may be overstated in view of the frequent use of corticosteroid injections, a lack of evidence of increased rates of tendon rupture with corticosteroid use, and the endstage tendon degeneration noted in tendon ruptures.18 Animal studies indicate that cortico-steroids weaken tendon whether injected into or proximal to the tendon, and it is possible that corticosteroid injections do lead to partial rupture of tendon substance. In non-weight-bearing tendons or patients who place little demand on the affected tendon through heavy loading at work or playing sport, this may lead to symptom abatement through a “medical tenotomy”, with surprisingly little functional loss. Partial tendon rupture in weight-bearing tendons or patients who place higher demand on the tendon is much more significant, and frequently necessitates surgery. Thus, the evidence suggests that a single corticosteroid injection for symptomatic tendon injuries may achieve a mild, short-term reduction in pain for up to 6 weeks, particularly for “non-critical” tendons where rupture may not be a deleterious outcome. This injection should be coupled with a tendon-specific rehabilitation program. Where actual tendon healing is critical to a good outcome, such as overuse injuries to major weight-bearing tendons like the Achilles, corticosteroid injections are probably contraindicated. Prolotherapy and aprotinin injectionsProlotherapy generally refers to the injection of a sclerosant such as phenol, or hypertonic glucose. Theoretically, sclerosants may be useful for soft-tissue conditions, such as ligament injuries, in which joint laxity is an issue. There are no controlled studies examining prolotherapy as a treatment for soft-tissue injury, although there is some low-level evidence supporting prolotherapy for back pack pain and osteoarthritis.19 Given the lack of evidence of efficacy, prolotherapy cannot yet be recommended for treating soft-tissue injury. Its major advantage is that side effects of treatment are likely to be minimal. Aprotinin is a broad-spectrum metalloprotease (MMP) inhibitor used to treat many conditions, but particularly in preventing blood loss during cardiac surgery. Its use in chronic tendinopathy is attractive, as aprotinin may act as a collagenase inhibitor. Certain MMPs have been shown to be present in excessive proportions in patellar tendinopathy and rotator cuff tendinopathy, and aprotinin could potentially normalise the concentration of MMPs in chronic tendinopathy, which may help healing. In treatment for tendino-pathy as a series of two to four injections into the peritendinous space, aprotinin provides superior analgesia when compared with corticosteroid injections and placebo in patella tendinopathy (E2),20 and in Achilles tendinopathy (E3).21 Potential side effects include allergy and anaphylaxis, although death has only been reported when used intravenously for cardiac surgery; the “test dose” of 3–5 mL for major procedures is similar to the therapeutic dose for tendinopathy.22 The use of aprotinin injections for tendon injuries is currently an “off-label” indication. Botulinum toxin for tendinopathyBotulinum toxin type A is a neurotoxin which inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction, and inhibits skeletal muscle contraction. It results in reduced muscular spasticity, reduces pain and increased function in “whiplash-associated disorder” (E2).23 The use of multiple botulinum injections around the musculotendinous junction as a “last option” in the treatment of lateral epicondylosis has comparable results to extensor release surgery (E2);24 however, placebo injections demonstrate equal efficacy.25 These treatments may all induce local tissue healing responses. Side effects of botulinum injections include allergic reactions, and permanent muscle and tendon injury. Current evidence does not support the use of botulinum toxin injections for tendon injuries. An exception may be in chronic recalcitrant cases of lateral epicondylosis where surgery is considered. Glyceryl trinitrate treatment for tendinopathyGlyceryl trinitrate is a donor of nitric oxide (the endothelium-derived relaxing factor), but the mechanism of action of topical glyceryl trinitrate therapy on tendon is unknown. Nitric oxide inhibition decreases collagen content and collagen synthesis by fibroblasts,26 and nitric oxide donation may stimulate collagen synthesis by fibroblasts. In acute shoulder pain, there is evidence of an analgesic effect of 3 days duration (E2),27 which is of lesser efficacy than corticosteroid injections (E2).28 In chronic tendinopathies, topical glyceryl trinitrate therapy with 1.25 mg per 24 hours has level II clinical evidence of decreased pain, increased tendon force, improved functional measures, and improved symptom resolution in Achilles tendinopathy,29 lateral epicondylosis,30 and supraspinatus tendinopathy.31 Glyceryl trinitrate has a long history of therapeutic use in humans, and the common side effects of rash and headache are rapidly reversible on discontinuation of topical treatment. It should not be used concomitantly in patients taking phosphodiesterase inhibitors such as sildenafil (Viagra; Pfizer), as the additive effect may cause life-threatening hypotension. The use of topical glyceryl trinitrate for tendon injuries is currently an “off-label” indication, although medical practitioners may legally exercise discretion in prescribing this treatment for tendon conditions, provided likely effects, and side effects, such as rash and headache, are explained to the patient. Topical glyceryl trinitrate therapy has robust evidence of efficacy in treating common chronic tendinopathies, the side-effect profile is known and reversible, and this therapy should be used as an adjunct to tendon rehabilitation in chronic tendinopathies (Box 1). Glucosamine and soft-tissue injuriesGlucosamine has a significant analgesic effect in treating osteoarthritis, and it has been suggested that it may aid wound healing through enhanced fibroblastic production of hyaluronate (E5).32 There are no studies on glucosamine in treating soft-tissue injury. ConclusionBox 2 provides a flowchart summarising the evidence-based options for medical treatment of soft-tissue injuries. The widespread use of NSAIDs and corticosteroid injections in the treatment of most soft-tissue injuries requires reassessment based on current evidence, while new drugs such as aprotinin and glyceryl trinitrate hold promise as effective adjunctive treatment for chronic tendinopathies. Evidence-based guidelines on newer therapies There is evidence for the efficacy of topical glyceryl trinitrate therapy in treating common chronic tendinopathies (Achilles tendinopathy, lateral epicondylosis, and supraspinatus tendinopathy) (E2),27-29 and it can be used as an adjunct to tendon rehabilitation. Aprotinin provides superior analgesia compared with corticosteroid injections and placebo in patella tendinopathy (E2).18 This therapy may be particularly useful for chronic tendinopathy of the major weightbearing tendons, where the use of cortisone is contraindicated. Given the lack of controlled efficacy studies, prolotherapy cannot yet be recommended for treating soft-tissue injuries. Current evidence does not support the use of botulinum toxin injections for tendon injuries.23 There are no studies on the use of glucosamine in treating soft-tissue injuries. 1 Tendinopathies Tendon injuries, such as in lateral epicondylosis (tennis elbow, top) and tibialis posterior tenosynovitis (bottom), can be recalcitrant to treatment; conventional treatments such as non-steroidal anti-inflammatory drugs and corticosteroid injections may have a short term analgesic effect, while there is some evidence of efficacy with newer treatments such as topical glyceryl trinitrate therapy. 2 Evidence-based medical management of soft–tissue injuries NSAIDs = non-steroidal anti-inflammatory drugs.

Justin A Paoloni PhD, MSpMed, FACSP · John W Orchard MB BS, PhD, FACSP

Chris E Rissel Clinical Associate Professor, School of Public Health, University of Sydney, Level 9, King George V Building, Missenden Road, Camperdown, NSW 2050. crissATemail.cs.nsw.gov.au To the Editor: The editorial by Sharman about exercise and air pollution1 makes the point that cars contribute substantially to air pollution, and air pollution is known to have adverse health effects. Therefore, Sharman posits that exercise, which is unequivocally good for human health, is best done away from sources of air pollution. This “common-sense” maxim to avoid air pollution when exercising is superficially reasonable as far as it goes, but is a very weak response to the health and social problems generated by motor vehicles or the need for increased levels of physical activity in the population. With only half the Australian population achieving adequate levels of physical activity,2 recommendations to patients to be more physically active are essential. To simultaneously promote exercise and then put a health warning on this physical activity effectively undermines the recommendation. Part of the difficulty in judging the actual risks from air pollution and benefits of physical activity is that the science of pollutant exposure is not well understood at the individual level. It is not currently possible to say that exercising in a particular environment will have a net negative effect. Thinking laterally, perhaps physical activity even boosts the immune response in a way that helps the body resist adverse effects of air pollution? Perhaps only under more extreme conditions would outdoor activities need to be curtailed. One body of relevant research that Sharman did not consider is the research on pollutant exposure by travel mode, which clearly indicates that car drivers and passengers have pollutant exposures at least twice that of pedestrians walking on the same street.3,4 The longer people sit in cars, the greater their exposure to air pollutants, not to mention the increased risk of obesity.5 Therefore, a highly sensible approach is to recommend to patients that they avoid travelling in cars, particularly if the patient is sensitive to air pollutants or if traffic is congested. The most obvious common-sense solution to reduce air pollution and increase individual and population levels of physical activity is to recommend to patients that they replace short car trips with walking or cycling. As little as two 15-minute active transport trips per day can achieve recommended levels of physical activity to maintain health. It is possible to change travel behaviour, and this is a far better recommendation for all patients than telling them not to exercise near traffic.

Chris E Rissel

Louis A du Plessis Former Senior Lecturer, School of Applied Science, Riverina–Murray Institute of Higher Education, Wagga Wagga, NSW (retired). eldupeATbigpond.com To the Editor: Health professionals in the Sydney Greater Metropolitan Region have been found to be less aware of air pollution and its health effects than are patients susceptible to such effects.1 Therefore Sharman’s brief review of the harmful effects of air pollution is welcome.2 In offering advice on how to minimise the exacerbation of pollution-induced harm by exercise, Sharman concentrates on the spatial distribution and temporal variation of traffic. The advice is sound for the metropolitan population, but incomplete for non-metropolitan residents exposed to smoke from burning biomass. Australia’s National Environment Protection Measure defines limits for inhalable particulate matter suspended in ambient air (PM10). The NSW Department of Environment and Conservation operates a network of monitoring stations to measure PM10 and other pollutants, and posts the results daily on its Internet site <www.epa.nsw.gov.au/index.htm>. The National Environment Protection Measure requires environmental authorities to work towards reducing the number of days on which PM10 exceeds the daily limit to no more than 5 days per year. This goal is far from being realised in some places. One such place is Wagga Wagga, NSW, where monitoring of PM10 started on 11 April 2001. From that date up to 6 July 2005, the city experienced 118 days on which PM10 exceeded the limit, as well as many days of pollution near but below the limit. In the same period, monitoring stations in the Sydney Greater Metropolitan Region registered between 11 and 33 days of excess PM10. Of the 118 days of above-limit PM10 in Wagga Wagga, 30 occurred in the period from 30 October 2002 to 26 January 2003, when there were severe bushfires in south-eastern Australia. Most of the rest had a cause that is very evident in the surrounding countryside in autumn — the burning of paddocks to prepare them for sowing. Rural residents’ health is worse than urban residents’ health for many reasons, but biomass burning is not widely recognised as one of them. The Australian Medical Association’s Rural Reference Group, which is being convened to improve rural health,3 may wish to add environmental health to its agenda. There are two steps that the Group could take to lessen the effects of smoke from burning biomass. The first is to acquaint rural doctors with information such as that presented by Sharman. The second is to persuade the Department of Environment and Conservation and NSW Health to issue rural health warnings based on the continuous, real-time output of PM10 monitors in regional centres.

Louis A du Plessis

James E Sharman Postdoctoral Research Fellow in Cardiovascular Physiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102. jsharmanATsoms.uq.edu.au In reply: As emphasised in my editorial, regular aerobic exercise is to be encouraged, as it is of undeniable benefit to health.1 The crux of the intended message was for people to undertake an exercise program, but not near busy roads. There was no suggestion to curtail outdoor activities. Although the effect of traffic pollution on an individual is not well understood, there are many hundreds of scientific papers consistently finding that whole automotive pollution, or components thereof, damage biological tissue and promote disease.2 The World Health Organization recognises urban air pollution as a major risk to human health, with exposure to particulate matter alone accounting for an estimated 800 000 deaths a year globally.3 Would it be ethical to confine this information to the annals of scientific literature, or should some attempt be made to inform those who may be unknowingly and unnecessarily exposing themselves to veritable risk? People should have access to all the available information so that they can make an informed decision on where to exercise. Not only is it common sense, but it is entirely reasonable to suggest that people would be better off avoiding exercise alongside roadways congested with traffic. Quite separate to the question of exercising beside busy roads, but equally important from a health perspective, is the issue of persistently high ambient levels of particulate air pollution in certain regions. The air quality problem encountered in Wagga Wagga is exacerbated by geographical and climatic factors that encourage entrapment of air pollution, owing to a temperature inversion layer that is particularly apparent during winter. Other cities, such as Launceston, Tasmania, suffer the same fate and, in both cases, smoke from domestic wood-heaters is thought to be the biggest contributor to poor air quality. What are people to be told regarding exercise in these regions? It may be reasonably argued that habitual exercise in such environments would be detrimental to health, but it would be a very poor public health outcome if people were advised to stop exercising. In the affected areas mentioned, community education programs have been in existence for years, but these appear to be of limited value, as daily air pollution limits are regularly exceeded,4 as highlighted by du Plessis. Although unpopular, the answer lies in stricter regulations to clean the air, such as banning wood-heaters and tighter monitoring of rural burning.

James E Sharman

Objective: To review acute spinal cord injuries (ASCIs) in all Australian codes of football (rugby union [RU], rugby league [RL], Australian Rules football [ARF] and soccer) for 1997–2002 and to compare data with those of a 1986–1996 survey.Design: Retrospective review of hospital records, and structured interviews with injured players.Participants and setting: Patients admitted to any of the six Australian spinal cord injury units with a documented football-related ASCI over the period 1997–2002.Outcome measures: Average annual incidence of ASCIs per 100 000 players in the different codes, final Frankel grading of injuries, and wheelchair status.Results: Fifty-two footballers (45 adult men and seven schoolboys) suffered ASCIs between 1997 and 2002. The average annual incidence of ASCIs per 100 000 players was 3.2 for RU, 1.5 for RL, 0.5 for ARF and 0.2 for soccer. While there has been little change in incidence since the 1986–1996 survey, there has been a trend towards less severe injuries in RU and RL, but not in ARF. There have been no scrum injuries in RL since 1996, when the scrum stopped being contested. Seven injuries occurred in RU scrums, six at the moment of engagement of the opposing teams. The incidence of 2-on-1 and “gang” tackles (involving multiple tacklers) in RL is disturbing. Overall, 39% of injured players became permanently wheelchair-dependent.Conclusions: There continues to be good reason to revise the laws of scrum engagement in RU. The laws relating to multiple tacklers in RL should be examined. The insurance cover for injured players is grossly inadequate. The longstanding need for a registry of spinal cord injuries for all football codes regrettably remains unmet.

David J Carmody MB BS · Thomas K F Taylor DPhil(Oxon), FRACS · David A Parker FRACS · Myles R J Coolican FRACS · Robert G Cumming MB BS, MPH, PhD

Clinical sports medicine (2nd edition). Peter D Brukner and Karim Khan. Sydney: McGraw-Hill, 2001 (xxix + 918pp). ISBN 0 074 71108 3. This is the second edition of a highly successful local textbook that has sold over 40,000 copies worldwide. It is a staple recommended text for physiotherapists, sports medicine registrars and general practitioners in Australia and is also very popular in the USA and UK. It would be a particularly good reference text for orthopaedic surgeons who are experts in the major types of bone and joint pathology, but who would like information on the common types of sports injury that do not commonly present to hospital orthopaedic departments (eg, iliotibial band syndrome of the knee in runners; concussion; chronic groin pain; menstrual disorders in female athletes). Two major improvements have been made in the second edition. All chapters are now fully referenced, although most of the text remains easy to read. In addition, many chapters now have contributing authors who are international experts in their particular subject areas (eg, Ben Kibler on shoulder pain, Tim Noakes on exercising in the heat). Peter Brukner is an adjunct Associate Professor at the Centre for Sports Medicine Research and Education, University of Melbourne, and has vast experience as a team physician in athletics and Australian football. Karim Khan is an expatriate working as an Assistant Professor at the University of British Columbia, Vancouver, Canada, and a leading researcher in tendon injuries and bone health. John W OrchardSports physicianKensington, NSW Order this book

John W Orchard

To the Editor: Previous articles in the Journal have stressed the importance of making obesity prevention a public health research priority.1,2 Participation in physical activity is one important factor in counteracting increase in body weight.3 While recent studies have focused on environmental factors that influence walking (eg, presence of paths and trails, accessibility of destinations)4 and the possibility of environmental innovations to increase rates of participation, few studies have investigated participants’ perception and understanding of variation in physical activity in relation to environmental factors across the seasons. Our study aimed to examine how people perceive the impact of changes in ambient temperature and hours of daylight across the seasons on their rates of physical activity. We compared residents of the southern and northern hemispheres: a group of women from Sydney, Australia (n = 121; mean age, 19 years [SD, 2 years]), and a group of women from Trier, Germany (n = 109; mean age, 21 years [SD, 3 years]). Participants completed a brief written survey specifically designed for our study. The survey, using an “open question” format, asked participants to describe and explain any perceived changes in their physical activity during winter and summer. The majority of Australians and Germans perceived seasonal changes in physical activity (73.6% and 71.6%, respectively), with no significant difference between the two groups. These changes typically entailed a decrease in physical activity levels during winter (noted by 55.2% and 66.2% of Australians and Germans, respectively). A significantly higher number of Australians than Germans perceived a change from outdoor activities (eg, swimming) to indoor activities (eg, squash) between summer and winter (χ1 = 9.21; P = 0.002). Significantly more Germans than Australians perceived themselves to be affected by environmental factors (χ1 = 9.37; P = 0.002). These results support the contention that environmental changes are linked to changes in activity levels,5 and that more extreme climatic changes (such as those experienced by Germans compared with Australians) are associated with a greater perceived impact on levels of physical activity. Programs aiming to encourage greater participation in physical activity in winter need to challenge people’s perception of the impact of environmental factors by offering indoor opportunities for exercise, particularly to people from Germany. It appears that Australians are more aware of indoor opportunities for physical activity. Research into environmental factors that encourage or discourage walking4 needs to be taken into account when designing programs to enhance physical activity across the seasons. For example, constructing walking or cycling paths in the neighbourhood may encourage people to continue with indoor activities during the colder seasons by making the indoor venues more easily accessible.

Tanja Hechler · Josephine Y Chau · Sarah Giesecke · Silja Vocks

To the Editor: Pseudoephedrine is no longer a banned substance in sport.1 It was originally banned to protect athletes from overuse and its dangers. Has it become harmless or are athletes more intelligent? This highlights much of the confusion in drug testing. Athletes with diabetes are permitted to use insulin for therapy, but those with hypertension are not allowed to take β-blockers. Both drugs are popularly believed in athletic circles to improve performance. What is to stop an athlete with diabetes from taking extra insulin for performance enhancement? Why do we discriminate against those with hypertension? There is a ban on oxygen-transport drugs and on physical environment enhancers such as hypobaric chambers. Both are alleged to produce the same result, but only use of the drug can be tested. The penalty for the drug user is disqualification, but for the hypobaric enthusiast a rousing cheer for a drug-free effort. The crime is the same, so why vary the penalty? There is never likely to be a level playing field under the present system, in which one reads of positive test results being swept under the table. How will drug testing eliminate the genetic inequalities between athletes? How will testing improve the availability of top-level coaches and training facilities to all? How can it eliminate the inequality in financial incentives, allowing some athletes to train for 6 hours daily while others have to work to enable them to train for even 2 hours daily? We have swimming costumes that decrease drag in the water,1 resulting in faster times. These are not universally available, giving their owners an advantage. A level playing field will never exist in our present system. It is incongruous that in all this mess, only drugs are available to all. The current frenzy to test blood has ethical problems which have not been addressed.2 What is to happen to an athlete who develops an infection from a dirty needle? Who is responsible for the tester who has a needlestick injury from an HIV-positive athlete? It is worth remembering that this diagnosis will only be made 3 months after the Games, when everyone has dispersed. The whole area needs to be reviewed by an outside body with no vested interest in the outcome.

Anthony P Millar

Michael C Kennedy Research Associate, Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Darlinghurst, NSW 2010. drmkennATozemail.com.au To the Editor: Since the Sydney Olympics in 2000, many developments have occurred in drug use and the rules regulating drugs in sport. The most significant regulatory development is the acceptance by the Olympic Federation, and many other sports bodies, of the World Anti-Drug Agency’s World Anti-Doping Code.1 Caffeine and pseudoephedrine have been removed from the Prohibited List, and an in-competition monitoring program is under way to detect any changes in the patterns of use of caffeine, pseudoephedrine and other drugs not on the banned list. Had this code been used in 2000, the Romanian gymnast Andreea Raducan would have retained her gold medal, lost after she inadvertently used a cold preparation containing pseudoephedrine. Precise in-competition limits on blood and breath alcohol have been introduced in sports such as archery and modern pentathlon. β-Blocking agents and diuretics are completely banned in specific sports. A new category of “specified substances” now exists: . . . the prohibited list may identify specified substances which are particularly susceptible to unintentional anti-doping rule violations because of their general availability in medicinal products or which are less likely to be successfully abused as doping agents. These substances include cannabinoids, probenecid, glucocorticosteroids and ephedrine. Doctors treating athletes should advise them to inform their relevant sporting authority of drugs prescribed. If necessary, athletes can apply to the Australian Sports Drug Advisory Committee for a therapeutic use exemption for a banned substance. Notifiable substances can be documented on an Abbreviated Therapeutic Use Exemption form held by the national sporting body. There can be no doubt of the need for drug testing to ensure a level playing field. Drug use to enhance performance is unabated since the Sydney games, with scandals occurring around the world. The Bay Area Laboratory Corporation scandal, involving the anabolic steroid tetrahydrogestrinone, is the most prominent. This has ruined several sporting careers and led to criminal charges against company directors.2 Other anabolic steroids continue to be widely used, including nandrolone, which causes problems because of contamination of dietary supplements and some foods.3 One of the “holy grails” for drug cheats over the past 4 years has been to enhance oxygen transport and delivery. RSR13 (efaproxiral), an allosteric modifier of haemoglobin, is in clinical trial as a radiosensitising agent. It has been shown to increase Vo2max in dogs and hence has been of interest to endurance athletes. The manufacturer’s collaboration with the Olympic Analytical Laboratory of the University of California (Los Angeles) resulted in an analytical method now being available for detection of the drug in sport.4 Haemoglobin- and non-haemoglobin-based oxygen carriers are now available commercially. There are few scientific data about their use in sport, but it is likely they are misused by some athletes.5 Recombinant human erythropoietin is widely used in cycling and other endurance sports. A detection method developed from Australian research will limit its use, at least at the Olympic venue.6 Genetic manipulation is unlikely in 2004, but its potential is foreseen. This technology is also prohibited in the new code.1 Unfortunately, drugs will continue to be misused. The opportunity for Olympic winners to gain huge financial rewards will fuel their use.

Michael C Kennedy

Medical management of acute and chronic low back pain. An evidence-based approach. Nikolai Bogduk, Brian McGuirk. Amsterdam: Elsevier, 2003 (viii + 224 pp). ISBN 0 444 50845 7. Low back pain is a topic that has not enjoyed the publicity that it deserves in medical circles. With its limited coverage in medical curricula, both in hospital and GP training programs, one would be forgiven for thinking it is an uncommon or unimportant complaint. Yet it is a popular topic in the media where cure claims abound. It is also the leading cause of disability in the workplace and a very common cause of presentation to healthcare providers, often non-medical practitioners. The authors are well qualified to write about this topic: Bogduk is Professor of Pain Medicine at Royal Newcastle Hospital and McGuirk is a specialist in musculoskeletal and occupational medicine for the Hunter Area Health Service. They seek to redress many of the common misconceptions about low back pain by presenting an approach to diagnosis and management firmly supported by the evidence. Many readers may be surprised to hear that the evidence base for low back pain is stronger than that for most other common conditions, but that this evidence gives little support for the traditional orthopaedic approach. The evidence is presented with great clarity and links very logically with the algorithms for diagnosis and management. These algorithms gravitate towards precision diagnosis and treatment of the anatomical sources of back pain when conservative therapy has failed. This book is essential reading for people involved in musculoskeletal medicine and medicolegal work, for rehabilitation providers, physical therapists, WorkCover and other insurance providers, and for independent medical assessors. It would also be a very useful reference text for general practitioners and supersedes most other books in this area. Especially useful are the sections on history, imaging and management. These sections will save a lot of nail-biting among practitioners who are nervous of missing dangerous conditions, or who think they need to routinely refer low back pain patients to orthopaedic surgeons or rheumatologists. Health economists may also find the concepts in this book informative, as cost savings abound in this billion-dollar heath expenditure pit. C Scott MastersPresident, Australian Association of Musculoskeletal Medicine, Caloundra, QLD Order this book

C Scott Masters

Hot topics. Exercise. Manu V Chakravarthy, Frank W Booth. Philadelphia: Hanley and Belfus, 2003 (x + 326 pp). ISBN 1 56053 568 7. Tobacco smoking is still the leading preventable health risk in Australia, but the risk associated with a sedentary lifestyle is similar to that of smoking. For those Australians who do not smoke, physical inactivity is now by far the greatest health risk. Hot Topics. Exercise defines the key role that a sedentary lifestyle plays in the development of many common chronic health disorders and provides practical solutions to reversing this major trend in contemporary public health. The authors are two Americans whose professional lives are dedicated to increasing our understanding of the role of exercise in preserving human health. Chakravarthy is a physician and Booth a well-known clinical exercise scientist. The book provides a comprehensive account of the epidemiology, the biological mechanisms and the all-important randomised controlled trials that show that regular physical activity can prevent or delay the onset of chronic health disorders. In addition, the authors review the clinical evidence that exercise can reduce morbidity and enhance the quality of life of patients with a variety of chronic diseases. Through these various lines of evidence they establish clearly the health risk associated with a sedentary lifestyle. However, their purpose is not simply to extol the benefits of exercise. About one third of the book is devoted to sensible, practical exercise prescription and strategies to assist practitioners in guiding their clients and patients to more active lifestyles. Although medical practitioners may not be able to administer some of the types of exercise described, the section is important because it informs them about what is required and the advice they can expect their patients to receive from exercise specialists. The text is dense with information, but enjoyable to read and generously supported by tables, clear diagrams and flow charts. If we all act on the compelling arguments advanced in Hot Topics. Exercise we could reduce the health burden of sedentariness as we have reduced smoking-related diseases. The book will do much to encourage a vanguard. John R BrotherhoodSenior Lecturer School of Exercise and Sport Science University of Sydney, NSW

John R Brotherhood

There was an increase in the frequency of rugby union spinal injuries worldwide during the 1970s and early 1980s. The United Kingdom and Australia have since had some success in reducing this increase in spinal injuries. These changes were the result of actions by rugby union authorities in response to recommendations by medical advisors; legal action by injured players has also played a part. The frequency of spinal injuries has not decreased in New Zealand (up to 2000) and South Africa (up to 1997). Rugby union authorities’ responsibilities should include establishing and maintaining national and international spinal injury registers to forge closer working relationships with medical researchers. Such registers would provide up-to-date information for enhancing and developing preventive measures. There has been no specific publicly available record of the incidence of rugby union spinal injuries in Australia since 1996, so it is uncertain whether the safety measures introduced so far have had a lasting impact.

Paul T Haylen BECivil(Hons), MBA

John Orchard,* Caroline Finch† * Sports Physician, Sports Medicine Unit; † Director, NSW Injury Risk Management Research Centre, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: We agree with very few of the conclusions in the recent article by Mitton et al.1 It is fascinating that the authors single out elite athlete funding as being the only notable area of discretionary government spending that prevents more from being spent on healthcare. We suspect that the authors share the widely-held view within the healthcare professions that sport is an indulgence rather than a contributor to the good health of this nation. Sports medicine is the only recognised branch of medicine in Australia that is considered an “area” of medicine (all other recognised branches being considered “specialties”), a view held by both the Health Insurance Commission and the Australian Medical Association. Therefore, an Australian athlete who suffers a sports injury and is referred to a sports physician receives lower Medicare rebates for the visit than all other patients referred elsewhere in the system, and is unable to claim any Medicare rebate if he or she requires a magnetic resonance imaging scan for an injury, again the only such example in the Australian healthcare system.2 Injuries which occur as a result of traffic accidents, workplace accidents, falls, assaults and suicide attempts are all monitored by various government departments, with priority funding specifically directed towards their prevention. The federal government in Australia directs no funding towards sports injury monitoring or prevention3 and does not devote sufficient resources towards making the population more active.4 The article by Mitton et al ignores the concept of efficiency (in terms of prolonging life) within healthcare spending. Health promotion and prevention of illness and injury are far more efficient ways of prolonging life than treating existing disease (compare smoking cessation programs with coronary care units). Lack of sport and exercise is an increasingly prevalent risk factor for major diseases.4 The use of elite athletes as role models may or may not contribute to a more active population — we suspect the former. We also believe that the disrespect shown within the Australian healthcare system towards sports injuries (compared with other injuries and illnesses) is a major disincentive for Australians to become more active. This is a disincentive for which we will pay a high penalty in terms of decreased life expectancy and increased healthcare costs in the future.

John Orchard · Caroline Finch

Craig R Mitton,* H Dele Davies,† Cam Donaldson‡ * Assistant Professor, Department of Health Care and Epidemiology, University of British Columbia, 4480 Oak Street, E414 A, Vancouver, BC V6H3V4, Canada; † Professor, Pediatrics and Human Development, Michigan State University, USA; ‡ Professor, School of Population and Health Sciences and Business School, University of Newcastle, UK. cmittonATcw.bc.ca In reply: We thank Orchard and Finch for their letter about our article comparing spending on the Sydney Olympics to expenditure on healthcare for Australia, Canada and Britain.1 The reason we “singled out elite athlete funding” was simply to choose a high profile expenditure as an illustration that government does indeed make decisions about priorities with the limited societal resources available. While we would strongly agree, and in fact state, that “spending more on athletics may improve the health of the population”,1 the necessary public debate about how societal resources should be best spent is lacking. In our view, such a debate should be informed by the costs and wide-ranging benefits of government expenditure and be based on clearly articulated public values. Contrary to the claim that we “ignore the concept of efficiency”, it is precisely here, when costs and benefits of alternative claims on limited resources are explicitly compared (both within healthcare and across government sectors), that the notion of efficiency is addressed.2 Upstream investment in promotional activities may well be an appropriate way to spend health and non-health dollars — let’s just make these choices, and the underlying values, explicit.

Craig R Mitton · H Dele Davies · Cam Donaldson

During Australian Football League (AFL) grand final week in 2003, a three-day Football Australasia conference was held in Melbourne on 23–25 September, immediately after the annual conference of the Australasian College of Sports Physicians. The Football Australasia conference was attended by over 300 delegates, including doctors (sports physicians, general practitioners, orthopaedic surgeons and rheumatologists), other experts (such as physiotherapists, podiatrists and conditioning coaches), and representatives from Australian football, rugby union, rugby league and soccer. One of the achievements of the conference was the sharing of information across the football codes. Each topic (which focused on a body area, such as “shoulder injuries”, or a general issue, such as “career ending injuries”) established a list of controversial practical and research issues to be examined in over 100 presentations or posters and assorted panel discussions. Knee injuriesThe recent developments in autologous chondrocyte implantation for knee chondral defects1 were outlined by Ian Henderson (orthopaedic surgeon, Melbourne), who concluded that most professional footballers would find the 12 to 18 months currently required for satisfactory rehabilitation too lengthy. Merv Cross (orthopaedic surgeon, Sydney) spoke on the dilemma of meniscal tear repair for the professional footballer who must weigh up the short-term gains from early return to football after resection against the long-term benefits of retaining the meniscus, but taking a longer time to return to match play. Although current research supported the use of glucosamine after the development of joint degeneration,2 its role in prophylaxis against joint degeneration remains uncertain. Despite this, anecdotal evidence suggests that many professional footballers use glucosamine for this purpose (Geoff McColl, rheumatologist, Melbourne, personal communication). The prevention of anterior cruciate ligament (ACL) injury in footballers brought together experts in biomechanics, agronomy and epidemiology. Previous studies have implicated ground conditions as a potential cause of ACL injuries,3-5 and recent research conducted by Ian Chivers and David Aldous (turfgrass experts, Institute of Land and Food Resources, University of Melbourne) suggests that grass type and thatch depth, rather than ground hardness, is more closely linked with the incidence of ACL injury in AFL players. Julie Steele (biomechanist, Biomechanics Research Laboratory, University of Wollongong) reported on using supervised repetitive jump landing training to increase knee flexion angle and therefore reduce the risk of ACL injury from knee hyperextension.6 David Lloyd (biomechanist, School of Human Movement and Exercise Science, University of Western Australia) presented an update of ongoing research on balance training with single-leg stance on a wobble board (compared with traditional weight training), and indicated that balance training subsequently reduced stress on the ACL during side-stepping techniques.7 Vigorous debate raged over the choice of patellar versus hamstring tendon for surgical reconstruction of the ACL. The consensus was that previous injury to these structures and surgeon’s preference were the main determinants. Julian Feller (orthopaedic surgeon, Melbourne) outlined the results of a recent randomised controlled trial which supported the notion that patellar tendon grafts lead to higher morbidity, but greater stability, than hamstring grafts,8 a finding consistent with other studies.9,10 Shoulder injuriesFor a first-time glenohumeral subluxation or dislocation episode, Martin Raftery (Medical Coordinator, Australian Wallabies) broached the controversial subject of whether to manage this condition surgically or conservatively, favouring a trial of conservative management until the end of the season provides an opportunity to consider surgery.11 Brett Robinson (General Manager, Australian Rugby Union High Performance Unit, Sydney) disclosed that repetitive microtraumas to the glenohumeral joint in rugby lineouts, scrums, rucks and mauls (both in games and training) led to progressive instability, subluxation, possible internal impingement and, finally, rotator cuff tears. According to Daniel Biggs (orthopaedic surgeon, Sydney), the results of arthroscopic stabilisation of the shoulder were potentially similar to open shoulder stabilisation,12 except if there was significant bony abnormality, when an open procedure is preferred. ConcussionMichael Makdissi (Medical Officer to the AFL–Australian Institute of Sport U18 team) presented evidence that most AFL players who have concussion return to competition without missing a game, with no detrimental effects in performance, no increased risk of injury and no persistent defects in neuropsychological functioning. Testing after concussion increasingly involves a computer program that tests cognitive performance,13 which, in conjunction with clinical assessment, can be used as a guide to determining the safety of returning to sport. Hamstring and groin injuriesJohn Orchard (Team Physician, Sydney Roosters) identified the mechanisms of hamstring injury in football as overstriding when sprinting, bending to pick up the ball while running, or attempting to break out of a tackle.14 The risk of recurrence is high, and persists for 3 months after return to play, because players often return with subtle strength deficits, biomechanical compensations, or both.15 Geoff Verrall (sports physician, Adelaide) presented research identifying the role of magnetic resonance imaging (MRI) in predicting safe return to play (without recurrence) from hamstring strains by measuring the size of the lesion,16 whereas Uwe Proske (physiologist, Melbourne) explained that hamstring length could be moderated with eccentric exercise as a preventive measure against strains.17 Sallie Cowan (physiotherapist, School of Physiotherapy, University of Melbourne) reported research that identified delayed onset of transversus abdominis contraction in individuals with chronic groin pain. She hypothesised that this change in coordination of abdominal activity may leave the pubic symphysis unprotected from reactive forces, resulting in osteitis pubis. Geoff Verrall described a correlation between increased MRI signal intensity in the parasymphyseal bones and pain and tenderness in this area among athletes. Ankle sprainsThere was debate over the role of preventive ankle taping (strapping to reduce the risk of inversion sprain) in footballers. It was concluded that players who benefit most from taping are those with a past history of ankle sprains. Gordon Waddington (physiotherapist, School of Physiotherapy, University of Sydney) discussed football boots and injury prevention, including improving joint position discrimination by enhancing sensory stimulation to the plantar sole through insole design,18 and elite soccer players choosing to play in smaller-size boots to enhance proprioceptive feedback, ensuring better control of foot and ankle position, which perhaps enhances function and reduces injury. Andrew Jowett (Team Physician, Collingwood Football Club) suggested the characteristics of studs used on football boots may have an impact on the risk of ankle sprain in a similar way to their role in some knee injuries.3-5 Related issuesThat retired AFL players have a fourfold increase in risk of hip replacement and a twofold increase in risk of knee replacement compared with the normal population was confirmed by a survey reported by Matthew Hopkinson (physiotherapist, Melbourne).19 John Orchard reported that a 10-year survey of AFL doctors indicated that injury was a factor in 29% of players who are delisted from their clubs, with the proportion highly correlated with increasing player age. Hugh Hazard (Chief Medical Officer, National Rugby League [NRL]) spoke on the research that will contribute a basis for the NRL’s heat policy through predicting the meteorological factors (such as ambient temperature and humidity) that contribute to players’ heat stress (as measured by weight loss and core temperature increase). The conference clearly showed that football has become a fruitful area of research into prevention and management of sports injury and athletes’ performance. The AFL established a Research Board in 1999 to fund research into many aspects of football, and sports medicine has been a beneficiary of this support. The Australian Rugby Union is following suit, and it is hoped that the profile of broad research initiatives at the conference will prompt the NRL and the new Australian Soccer authorities to take similar initiatives. The attitude taken by the professional football bodies is praiseworthy, especially as research efforts are directed not only at the elite level, but also at more amateur levels.

Hugh G Seward MB BS, FACSP · John W Orchard MB BS, PhD, FACSP · Andrew D Jowett MB BS, FACSP

Medical orthopaedics. Conservative management of musculoskeletal impairments. Rene Cailliet. Chicago: AMA Press, 2004 ($106.30, xix + 217 pp). ISBN 1 57947 409 8. It is a monumental task to cover this huge topic in 200 pages. Professor Cailliet, however, has been writing about musculoskeletal impairments for the past three decades and has a knack for simplifying complex topics. He has previously found a receptive audience of over a million people. Undoubtedly, there is a thirst for knowledge in this field, as it is a common reason for seeking healthcare, but it is largely ignored by undergraduate training and hospital medicine, especially in Australia. This is a great pity, as a recent article in the Medical Journal of Australia1 revealed that musculoskeletal disability is the commonest cause of disability across all age groups in Australia. In the current "Decade of the Bone and Joint" it is encouraging to see that this black hole of medical education is receiving increasing attention. This book would be most attractive to the novice with little previous exposure to the field. It is easy to read, well illustrated and directive. The perspicacious reader will, however, be left unfulfilled. The peripheral joints are touched on so briefly I was left wondering why the author bothered at all. No mention was made of tendinopathies or frozen shoulder syndrome and the knee chapter was five pages long. On the positive side there is reasonable coverage of low back and neck pain, with an emphasis on the importance of ruling out red flags, avoiding rest, confident explanation, attention to psychosocial factors and limiting radiological exposure. Chronic regional pain and fibromyalgia are awarded a chapter each. The pathophysiology of these two syndromes is yet to be unravelled, but patients with these conditions seek help frequently and widely. Dissemination of quality information about both these topics is vital and this book helps in this task. Strangely, there is little reference throughout the text about the level of evidence for statements. Instead, we are given statements such as "therapists agree", "exercises are desirable" and "salicylates are of value". I suspect many readers would like to know more about the effect size of treatments rather than these global proclamations. C Scott MastersGeneral PractitionerCaloundra Sports Medicine Centre, QLD 1. Giles LC, Cameron ID, Crotty M. Disability in older Australians. Med J Aust 2003; 179: 130-133. Order this book New books | All books | Search | Information | Contact | eMJA Home © 2004 Medical Journal of Australia

C Scott Masters

Sports injuries and emergencies. A quick-response manual. Aaron Rubin. New York: McGraw-Hill, 2003 (xvii + 470 pp). ISBN 0 07 139610 1. Aaron Rubin has assembled a team of 46 doctors, athletic trainers and paramedical personnel from across the United States to produce a book which is intended for use as a handbook for the doctor sitting on the sidelines at American sporting contests. It should be recognised that in the US training to practise sports medicine is one of the many elective professional development programs a doctor can undertake. These "fellowships" generally take about 1 year and are added to an intern/residency program. This book is pitched at the resident undertaking some first-hand training in sports medicine and, no doubt, caring for athletes at College level undertaking various sporting activities. The book covers all the usual topics in orthopaedic and musculoskeletal injuries, cardiovascular and respiratory emergencies, as well as medical conditions such as asthma, exercise-induced bronchospasm, and the treatment of cardiac arrest. There are chapters on subjects such as the psychology of injury, and a number of appendices which describe the team physician’s bag, the athletic trainer’s kit, emergency medical supplies etc. The book does focus on specific sports- related injury and gives very useful guidelines for management for each of these diagnoses. It would certainly serve as a useful tool for the doctor sitting on the sidelines at a competition. The book is well illustrated, and each chapter contains a few useful current references. The authors were not all well known to me. However, some of the names were familiar as experts in their respective areas within the domain of sports medicine. As a clinician interested in sports medicine, I found it an easy read, notwithstanding its very American focus. The book does fill a gap in the market in that it is directed at a more sophisticated "first-aid for sport" niche. I did not find anything in the book with which I would strongly disagree, and the book is topical. I note the retail price inscribed on my reviewer’s copy was $119.95 (presumably Australian dollars) and I would say this is expensive for a handbook. It would be valuable, though, among its target readership. Peter A FrickerChair of Sports Medicine University of Canberra, ACT Order this book

Peter A Fricker

Handbook of sports medicine and science. Strength training for sport. William J Kraemer, Keijo Hakkinen (editors). Oxford: Blackwell Science, 2002 (x + 186 pp). ISBN 0 632 05568 5. Few areas of sports medicine are as plagued by mythology and unscientific jingoism as the area of strength training. Methods used vary according to the environment in which the training is conducted. Different sporting codes have different traditions, and coaches tend to have their own set of beliefs or bias, often the result of their own sporting experiences. This book provides a very readable overview of the principles and practical applications of strength training. Its most impressive feature is that each chapter is heavily referenced from peer-reviewed journals, providing credibility in an area renowned for quackery. The authors begin with a history of strength training and a thorough explanation of the underlying scientific principles. The chapter on neuromuscular adaptions provides fascinating reading. For those who work with sporting teams, the authors provide practical advice on how to develop a strength training program. Issues such as periodisation of training programs are covered, as well as examples of strength training programs for various specific sports. Special considerations, such as differences between the sexes, junior athletes, the aged and overtraining, have all been addressed. The information is presented in a format suited for practical application. There are plenty of illustrations, point form summaries and graphical representation of data. This is an excellent book for those involved with athletes or those wishing to understand the science behind strength training. My only criticism is its failure to deal with the controversial and difficult area of nutrition for strength training. Sports supplementation is one of the boom areas of athlete exploitation, with aggressive marketing of substances that are often unproven and potentially dangerous. A chapter on nutritional aspects would have rounded off what is otherwise an excellent publication. David C HughesSports Physician Deakin, ACT

David C Hughes

To the Editor: In their recent article, Makdissi and Brukner stated that resumption of play should follow the "30/30" rule.1 In the article, the authors cited three references, each of which relates to position statements rather than to any scientific reference that "blue skies and lack of rainfall are not adequate reason to breach the 30 minute return to play rule".2-4 Unless there are reasonable scientific explanations why lightning should strike someone in the presence of blue skies, I would think that this policy needs some reconsideration. It seems logical that if a storm is moving away, the skies should become blue, and the time between lightning and thunder should increase. I would have thought that if there was a weather watcher around, he or she could monitor the situation, and ascertain that the storm was moving away, and this would allow for earlier resumption of sport. Can you imagine a weather watcher preventing play in an AFL game, or even a minor suburban game of football, because of the threat of lightning if the skies were indeed blue? If I am to take this recommendation to my local football club, I would like to see evidence that this has some credible scientific backing.

David Vivian